Bobby Caina Calvan at the Sacramento Bee writes, Can health providers handle influx of newly insured?:
Across the country, as many as 32 million of the country's 46 million uninsured could soon have improved access to affordable health insurance – through government subsidies or by becoming eligible for Medicaid programs such as Medi-Cal.
Whether the system will be ready to receive them remains a significant unknown. The influx of new patients may strain the nation's supply of primary care physicians. But at the same time, it could ease the burden on county clinics and emergency rooms, which currently provide care to those who lack insurance.
William Sandberg, executive director of the Sierra Sacramento Valley Medical Society, said his organization polled 531 of its members in January to ask if there would be enough primary-care physicians to handle the deluge of new subscribers. They reportedly gave a resounding "no."
The deficit of primary-care physicians nationwide is nothing new.
The annual number of American medical students who go into primary care has dropped by more than half since 1997. It's hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. ...
The reason behind America's doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it's easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.
The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments.
Many kinds of solutions to this growing problem have been suggested, and some are being tried out in various places. Medical schools offer training programs for medical students that affords them a chance to work in primary care in diverse, under-served settings. Tufts, for instance, provides a "$25,000-a-year scholarship for med students who agree to work in primary-care practices in rural Maine for much of their training period." But the program only has 36 slots each year, and students aren't required - can't be - to actually go into primary care as a career choice. And even if they could be, it wouldn't fill the gap:
"We need more than half of doctors in this country doing primary care," says Harris Berman, interim dean of the medical school at Tufts. "It's a bigger problem than we can solve with programs like ours."
Some considerable help is on the way thanks to Sen. Bernie Sanders. His efforts amending the Senate health care reform bill mean that federally qualified community health centers will be getting $9.5 billion in operational funds, allowing - over five years - an expansion from 1200 to 10,000 clinics nationwide serving low-income clients on a sliding scale. Additional billions will go to building clinics and will help provide education through the National Health Service Corps, for 17,000 new primary-care practitioners, dentists, nurses and other healthcare professionals. The reconciliation bill contains a bit more money for this purpose.
In exchange for two to four years of service in an NHSC-approved site in a "Health Professional Shortage Area," tuition, fees and some living costs are covered for students in training to become primary care physicians, dentists, nurse practitioners, certified nurse-midwives or physician assistants. The program already received $200 million boost from the American Recovery and Reinvestment Act last year. In its 38 years, more than 30,000 students have served in the corps, with about half making a career of doctoring under-served populations. NHSC providers care for 4 million patients each year.
Out of necessity, at many HMOs and some clinics, especially in rural and small-town settings, physicians assistants and nurses now handle patient needs that were once the sole bailiwick of primary-care doctors. A few clinics operate teams of P.A.s, nurses and others supervised by a physician. The distinct advantage of this approach is that it takes a shorter time and less money to train these caregivers.
In seeking "fixes" to the health care legislation that is now the law of the land, there are also other creative solutions that the government might imitate. As Susan Bruce noted recently at Main Street:
A small town in northern NH was fortunate enough to have one solution given to them. A wealthy summer resident of Tamworth, NH, started the Tamworth Community Nurses Association. Mrs. Elizabeth Whittemore left behind an endowment so that all residents of Tamworth could have access to health care. That was over 80 years ago. The town of Tamworth still has a nurse that sees patients in her office or makes house calls. Free.
Not every community has a wealthy benefactor. But Tamworth's is the kind of program that government-private partnerships could establish.
Reasonable set-ups like these cannot, however, wholly substitute for the needed increase of primary-care practitioners. And as long as payments for specialists remain far higher than what primary-care physicians can command, it will be difficult to attract the needed numbers. Dealing with that conundrum will take more than a couple of brainstorming sessions. There are models at home and abroad that ought to be investigated.
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